EUROPEAN RESPIRATORY REVIEW

SERIES
F. LAMOTH AND T. CALANDRA

Pulmonary aspergillosis: diagnosis and treatment

Frederic Lamoth1,2 and Thierry Calandra1

Number 7 in the Series “Respiratory infections”

Edited by Antoni Torres and Michael S. Niederman

1
Infectious Diseases Service, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne,
Switzerland. 2Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.

Corresponding author: Frederic Lamoth (Frederic.Lamoth@chuv.ch)

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Cite this article as: Lamoth F, Calandra T. Pulmonary aspergillosis: diagnosis and treatment. Eur
Respir Rev 2022; 31: 220114 [DOI: 10.1183/16000617.0114-2022].

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16000617.0150-2022
Abstract
Aspergillus species are the most frequent cause of fungal infections of the lungs with a broad spectrum of
clinical presentations including invasive pulmonary aspergillosis (IPA) and chronic pulmonary aspergillosis
(CPA). IPA affects immunocompromised populations, which are increasing in number and diversity with
the advent of novel anti-cancer therapies. Moreover, IPA has emerged as a complication of severe
influenza and coronavirus disease 2019 in apparently immunocompetent hosts. CPA mainly affects patients
with pre-existing lung lesions and is recognised increasingly frequently among patients with long-term
survival following cure of tuberculosis or lung cancer. The diagnosis of pulmonary aspergillosis is
complex as it relies on the presence of clinical, radiological and microbiological criteria, which differ
according to the type of pulmonary aspergillosis (IPA or CPA) and the type of patient population. The
management of pulmonary aspergillosis is complicated by the limited number of treatment options, drug
interactions, adverse events and the emergence of antifungal resistance.

Received: 15 June 2022

Accepted: 18 Sept 2022
Introduction
Aspergillosis, caused predominantly by Aspergillus fumigatus, is the most frequent mould infection of the
lungs. The spectrum of the disease is broad and depends on the immune status of the host. A. fumigatus
can cause allergic reactions in the lungs of patients with asthma or cystic fibrosis known as allergic
bronchopulmonary aspergillosis (ABPA) [1]. Chronic pulmonary aspergillosis (CPA) affects individuals
who are immunocompetent or mildly immunocompromised and have underlying lung disease, such as
chronic obstructive pulmonary disease, sequelae of tuberculosis, nontuberculous mycobacterial infections
or lung cancer [2]. There are distinct patterns of CPA with overlapping clinical presentations ranging from
simple aspergilloma (a fungus ball within an existing cavity) to chronic cavitary, fibrosing and
microinvasive forms of pulmonary aspergillosis [2]. Subacute invasive aspergillosis, also known as
semi-invasive or chronic necrotizing aspergillosis, refers to a chronic pulmonary form of the disease
evolving towards invasion and necrosis of adjacent lung tissues in mildly immunocompromised patients
[2]. Acute invasive pulmonary aspergillosis (IPA) affects patients who present with various degrees of
immune suppression in the context of haematologic malignancies, chemotherapy-induced neutropenia or
immunosuppressive therapies for autoimmune disorders or following bone marrow or solid organ
transplantation [3]. IPA has also emerged among intensive care unit (ICU) patients under mechanical
ventilation for severe influenza or coronavirus disease 2019 (COVID-19) and who are apparently
immunocompetent [4–6].

Aspergillus fumigatus represents by far the most common cause of aspergillosis, followed by Aspergillus
flavus (more predominant in some regions of Africa or Asia), Aspergillus terreus and Aspergillus niger [7, 8].

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Other pathogenic species account for less than 3% of cases and include Aspergillus nidulans, Aspergillus
calidoustus, Aspergillus glaucus, Aspergillus versicolor and some cryptic species (e.g. Aspergillus lentulus,
Aspergillus udagawae).

Pulmonary aspergillosis poses a diagnostic and therapeutic challenge because of the modest sensitivity and
specificity of diagnostic tests resulting in frequent diagnostic and therapeutic delays, limited therapeutic
options, significant drug interactions (especially for triazoles), adverse events, and the emergence of
resistance. The purpose of this review is to discuss current diagnostic and therapeutic approaches, recent
advances and future perspectives in the management of IPA and CPA. Allergic Aspergillus diseases (i.e.
ABPA) will not be discussed here.

Diagnosis
IPA
Because of the paucity of clinical signs and the limited sensitivity and/or specificity of radiology and
mycological tests, the diagnosis of IPA is graded according to a scale of probability ( possible, probable or
proven) of disease. The European Organization for Research and Treatment of Cancer and Mycoses Study
Group Education and Research Consortium (EORTC-MSGERC) has established definitions for the
diagnosis of possible, probable and proven IPA in immunocompromised patients [9]. These definitions rely
on host criteria (immunosuppressive conditions), clinical criteria (clinical and radiological signs of IPA)
and mycological criteria (results of direct or indirect microbiological testing for Aspergillus species)
(figure 1) [9].

Because initial clinical symptoms of IPA are often absent or not specific (e.g. fever), chest computed
tomography (CT) scan represents a cornerstone of the diagnostic approach and should be performed
whenever IPA is suspected in an immunocompromised patient [10]. On the contrary, standard chest
radiography has poor sensitivity and is not considered appropriate for screening [10].

The available mycological tests for IPA diagnosis include histological examination of biopsy or surgical
specimens, culture and nonculture methods, such as fungal biomarkers (galactomannan, 1,3-β-D-glucan
(BDG)) and PCR [11, 12]. The different commercial tests and their characteristics are presented in table 1.
Galactomannan (GM) testing can be performed in serum and bronchoalveolar lavage (BAL) fluid while
the BDG test is only validated for use in serum. Whereas GM is a relatively specific marker of IPA, BDG
can detect a broad range of pathogenic fungi including Aspergillus and Candida species with some
exceptions (e.g. Mucorales) [11]. Multiple in-house PCRs have been developed for the detection of
A. fumigatus or Aspergillus species. Recently, the European Aspergillus PCR Initiative has established
laboratory procedures to improve the standardisation of these assays [13]. Moreover, some kits for the

Host Clinical Mycological Proof of

criteria criteria criteria invasion

Immunosuppressive conditions Suggestive radiological pattern
(e.g. haematologic cancer, on chest CT (e.g. nodule, mass
transplantation, treatment with +/– halo sign, air crescent sign,
immune-modulating agents, etc.) etc.)
Possible
Positive direct exam or culture in
nonsterile sites (BAL,
bronchial aspirate or sputum)
OR
Positive galactomannan and/or
PCR (serum or BAL)
Positive histopathology (+/– PCR),
direct exam or cultures in sterile sites
(e.g. lung biopsy or pleural fluid)
AND
Evidence of infection
(histological, radiological or clinical)

Probable

Proven

FIGURE 1 Schematic representation of the diagnostic classification of invasive pulmonary aspergillosis (IPA)
according to the European Organization for Research and Treatment of Cancer and Mycoses Study Group
Education and Research Consortium. Possible IPA must include at least one host criterion and one clinical
criterion. Probable IPA must include at least one host criterion, one clinical criterion and one mycological
criterion. Proven IPA is defined independently from the presence or absence of host/clinical/mycological
criteria. For details, see reference [9]. BAL: bronchoalveolar lavage; CT: computed tomography; PCR: specific
polymerase chain reaction for Aspergillus species.

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TABLE 1 Characteristics of nonculture commercialised diagnostic tests for invasive pulmonary aspergillosis

Target Type of test Technique Spectrum of detection Type of sample Cut-off

(manufacturer)

Galactomannan PlateliaTM Aspergillus EIA Immunoenzymatic sandwich 0.5–1.0 ODI¶

(Bio-Rad) assay
Soña Aspergillus Immunochromatographic Visual reading or
galactomannan LFA (IMMY) assay (LFA) All Aspergillus species cube reader:
Serum, BAL
(specific)# 0.5–1.0¶ (index
values)
Aspergillus galactomannan Chemoluminescent assay 1.0 (index value)
VirCliaTM (Vircell)
(1→3)-β-D- FungitellTM (Associates of Colorimetric assay 60–80 pg·mL−1§
Glucan Cape Cod) (microplate)
Fungitell STATTM Colorimetric assay (single 0.75–1.2 (index
(Associates of Cape Cod) tube) values)§
All Aspergillus species
Wako β-glucan test Turbidimetric assay (single Serum 7.0 pg·mL−1
(not specific)+
(Fujifilm Wako Chemicals) tube)
70–95 pg·mL−1
§
Dynamiker Fungus (1–3)- Colorimetric assay
β-D-glucan (Dynamiker (microplate)
Biotechnology)
Aspergillus DNA MycAssay AspergillusTM Real-time PCR (18S rDNA) Most relevant Aspergillus NA
(Myconostica Ltd., now species
Microgen Bioproducts Ltd.)
AsperGeniusTM Multiplex real-time PCR (28S Most relevant Aspergillus NA
(PathoNostics) rDNA and Cyp51A) species, Cyp51A mutations
(L98H, TR34, BAL, other
T289A, Y121F) respiratory
MycoGenieTM (AdemTech) Real-time PCR (28S rDNA and Aspergillus fumigatus, samples, serum NA
Cyp51A) Cyp51A mutations
(L98H, TR34)
Fungiplex Aspergillus Multiplex real-time PCR Aspergillus species, Cyp51A NA
azole-RTM (Bruker (TR34, TR46)
Daltonics GmbH)
Note: the table is limited to the most relevant currently available test methods. BAL: bronchoalveolar lavage; EIA: enzyme immunoassay; LFA: lateral
flow assay; NA: not applicable; ODI: optical density index. #Cross-reaction with some other fungal pathogens, e.g. Fusarium, Histoplasma. ¶ODI 0.5 is
recommended by the manufacturer. Higher cut-offs (e.g. 1.0) are recommended for better specificity, notably in non-serum samples (BAL,
cerebrospinal fluid). +Detection of most other fungal pathogens with some exception (e.g. Mucorales). §Values below, within and above this range
are considered as negative, indeterminate and positive, respectively.

direct detection of Aspergillus species in clinical samples are now commercially available (table 1). Some
of these assays also provide detection of the most important mutations associated with azole resistance.

As the clinical presentation, diagnostic work-up and performance of diagnostic tests of IPA can vary
considerably according to the type of disease and patient population, we will review the characteristics of
diagnostic approaches in different settings.

IPA in haematologic cancer patients

Allogeneic haematopoietic stem cell transplant (HSCT) recipients with graft-versus-host disease (GVHD)
and patients with acute leukaemia and prolonged chemotherapy-induced neutropenia (i.e. >10 days)
represent the groups of patients at highest risk of IPA with an incidence of 2–8% [14–18]. However, IPA is
now diagnosed with increasing frequency among other onco-haematologic populations formerly considered
at “low risk”, such as patients with lymphoma, multiple myeloma or chronic leukaemia [8, 19–21].
Moreover, novel anti-cancer therapies, such as the Bruton tyrosine kinase inhibitors (e.g. ibrutinib) have
been associated with an increased risk of IPA [22].

Neutropenic haematologic cancer patients usually have pathognomonic radiological findings on chest CT,
such as well-circumscribed dense lesions (nodules or masses) with or without a surrounding area of
ground-glass opacity due to haemorrhage known as the halo sign [10]. The halo sign usually represents an

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early stage of the disease, while the air crescent sign ( partial cavitation) and the presence of a cavity are
later-stage radiological manifestations with poorer prognosis [10, 23].

In haematologic cancer patients, the yield of direct exam and cultures for Aspergillus detection is
notoriously low (around 20% and 50%, respectively) [24–26]. Nonculture methods, in particular GM or
PCR in serum or BAL, are the cornerstone of IPA diagnosis and are in more than 50% of cases the only
mycological markers of IPA [8, 12, 25, 27]. Their sensitivity and specificity are presented in table 2.
Overall, GM and PCR exhibit comparable diagnostic performances and their combined use in serum or
BAL samples results in the highest sensitivity and specificity [28–30]. BDG testing in serum is not
specific for Aspergillus species and is associated with some false-positive results in this population,
notably among patients who have received intravenous immunoglobulins [11, 31, 32].

The epidemiology and diagnostic approach of IPA has changed with the increasing use of posaconazole
prophylaxis in high-risk patients [33, 34]. Therefore, serial screening of GM in serum is not recommended
in patients under posaconazole prophylaxis because of the low incidence of IPA, which results in low
positive predictive value of the test [34, 35]. However, a pre-emptive approach with serial serum GM
screening (e.g. twice per week) represents an alternative to systemic antifungal (AF) prophylaxis in these
high-risk patients [34]. Chest CT scan should be performed in case of persistent or recurrent febrile
neutropenia despite broad-spectrum antibiotics or in case of a positive serum GM. Bronchoscopy with
BAL should be considered in the presence of a lung lesion consistent with IPA at CT scan. Indeed, BAL
samplings are associated with the highest sensitivity and specificity to detect IPA (table 2) [12]. An
algorithm for the diagnostic work-up of IPA in high-risk haematologic cancer patients is presented in
figure 2. Patients with a positive serum GM have a worse prognosis, because of more advanced disease,
which suggests that clinicians should have low threshold to perform chest CT for early detection of IPA [24].

For other haematologic cancer patients at lower risk of IPA (e.g. chronic leukaemia, lymphoma, autologous
HSCT recipients), anti-mould prophylaxis or serial GM screening are not recommended, but the threshold
of clinical suspicion should be low to trigger chest CT and further investigations as IPA diagnosis is often
missed in this population [19].

TABLE 2 Performance of galactomannan (GM) and Aspergillus PCR in serum and bronchoalveolar lavage fluid
(BAL) for the diagnosis of invasive pulmonary aspergillosis (IPA) in haematologic cancer patients: results of the
most relevant meta-analyses

Fungal biomarker Study Sensitivity (%) (95% CI) Specificity (%) (95% CI)

Serum
GM PFEIFFER et al. [38] 58 (52–64) 95 (94–96)
LEEFLANG et al. [98]¶ 78 (70–85) 85 (78–91)
ARVANITIS et al. [28] 92 (83–96) 90 (81–95)
PCR MENGOLI et al. [99] 88 (75–94) 75 (63–84)
ARVANITIS et al. [28] 84 (71–92) 76 (64–85)
GM and PCR# ARVANITIS et al. [28] 99 (96–100) 98 (94–100)
BAL
GM GUO et al. [100]¶ 85 (72–93) 94 (89–97)
AVNI et al. [29]¶ 85 (62–95) 100 (97–100)
ZOU et al. [101]¶ 86 (76–92) 95 (91–97)
HENG et al. [30] 75 (55–88) 95 (87–98)
DE HEER et al. [102]¶ 78 (61–95) 93 (87–98)
PCR SUN et al. [103]¶ 91 (79–96) 92 (87–96)
AVNI et al. [29]¶ 93 (70–98) 98 (93–99)
ZOU et al. [101]¶ 82 (61–93) 98 (85–100)
HENG et al. [30] 57 (31–80) 99 (60–100)
GM and PCR# AVNI et al. [29]¶ 97 (83–99) 97 (93–99)
HENG et al. [30] 84 (79–88) 94 (91–97)
Results are displayed for the diagnosis of proven and probable IPA. For GM, results are displayed for the cut-off
of optical density index 0.5 for serum and 1.0 for BAL. #Where a positive result is considered as either GM or
PCR positive and a negative result as both GM and PCR negative. ¶Mixed populations, but with a predominance
of haematologic cancer patients.

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Prophylactic approach
Posaconazole prophylaxis
High-risk IPA
Patients with acute leukaemia and
prolonged neutropenia (e.g. >10 days)
OR
Allogeneic HSCT recipients with GVHD Pre-emptive approach
Serum GM monitoring (twice weekly)

Positive GM in serum (ODI ≥0.5)

Persistent (≥3 days) or recurrent OR
Chest CT scan
neutropenic fever Persistent (≥3 days) or recurrent
Lung lesion neutropenic fever
consistent with IPA ?

Bronchoscopy with BAL

IPA diagnosis Probable Suspected but not

fulfilling
EORTC/MSGERC
criteria
Serum GM Negative Negative Positive Positive Positive
Chest CT Positive Positive Positive Positive Negative

Negative or not performed Positive Negative or not performed Positive Not performed

AF therapy Repeat serum GM

Intervention Reassess (follow-up CT) AF therapy Extrapulmonary IA?
+/– Biopsy of lesion (brain MRI, abdominal CT)

FIGURE 2 Diagnostic approach of invasive pulmonary aspergillosis (IPA) in high-risk haematologic cancer patients. AF: antifungal; BAL:
bronchoalveolar lavage; CT: computed tomography; EORTC/MSGERC: European Organization for Research and Treatment of Cancer and Mycoses
Study Group Education and Research Consortium; GM: galactomannan; GVHD: graft versus host disease; HSCT: haematopoietic stem cell
transplantation; IA: invasive aspergillosis; MRI: magnetic resonance imaging; ODI: optical density index; PCR: specific polymerase chain reaction for
Aspergillus species.

IPA in solid organ transplant recipients

The incidence of IPA among solid organ transplant (SOT) recipients is estimated to be 1–3% [36, 37]. It is
higher among heart and lung than in other organ transplant recipients. The diagnosis of IPA in this
population is difficult because of the lower specificity of radiological findings and lower sensitivity of
mycological tests compared to those observed in haematologic cancer patients. Chest CT findings of IPA
in SOT are not limited to well-circumscribed lung lesions (e.g. nodules or masses), but include a wide
range of nonspecific abnormalities that cannot be distinguished from bacterial or viral pneumonias, such as
tree-in-bud patterns, lobar infiltrates or ground-glass opacities [10].

The sensitivity of GM in serum is lower (around 40%) in SOT than in haematologic cancer patients [38].
BDG has poor sensitivity and specificity in this population [31, 39]. However, overall performance of GM
and PCR in BAL is comparable to that reported in haematologic cancer patients with notably a similar
high performance for their combined use [40, 41].

There is no recommendation for serial monitoring of serum fungal biomarkers in SOT patients because of
their limited sensitivity and specificity [34]. In case of clinical suspicion (e.g. suggestive chest CT lesion),
bronchoscopy should be performed and combined use of mycological tests (culture, GM, PCR) in BAL is
the cornerstone for IPA diagnosis.

IPA in other immunocompromised hosts

Data about the performance of culture and nonculture diagnostic tests of IPA among patients with other
immunosuppressive conditions (e.g. auto-immune diseases, corticosteroid therapy, treatment with Bruton
tyrosine kinase inhibitors) are lacking. However, it is expected to be comparable to that observed in other
nonneutropenic populations, such as SOT recipients.

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IPA in ICU patients

The incidence of IPA in ICU is highly variable. Patients with severe influenza or COVID-19 are at the
highest risk with reported incidences ranging from 5 to 30% [42]. There is more evidence supporting the
association of IPA and influenza with one control study demonstrating a significantly higher incidence of
IPA among ICU patients with severe influenza compared to those with other community-acquired
pneumonia [6]. Moreover, evidence of angio-invasion, based on a positive GM in serum or histopathology,
is more frequent in influenza than in COVID-19 [42–44]. In the latter, the distinction between Aspergillus
colonisation and true IPA is difficult [45, 46]. However, recovery of Aspergillus in a respiratory sample by
direct or indirect diagnostic tests seems to be a marker of poor prognosis in both influenza and COVID-19
patients [4, 6]. Other conditions that may predispose to IPA among ICU patients include liver cirrhosis,
extracorporeal membrane oxygenation and short courses of corticosteroids [5, 47, 48].

IPA should be suspected in intubated patients with deteriorating respiratory conditions despite
broad-spectrum antibiotic therapy. Chest CT findings are usually not distinguishable from viral or bacterial
pneumonias [5, 42, 49, 50].

The EORTC-MSGERC criteria for IPA do not apply in ICU patients who do not have host criteria of
immunosuppression in most cases. Customised definitions have been proposed for IPA in ICU, and
specifically for IPA in patients with influenza or COVID-19 [49–51]. While the distinction between
Aspergillus colonisation of the airways and true IPA is difficult to assess in this setting, the diagnostic
criteria usually rely on a positive test for Aspergillus (direct exam, culture, GM or PCR) in a BAL sample.
The significance of positive results in nonbronchoscopic respiratory samples (e.g. bronchial aspirates) is
more difficult to interpret. GM in serum has a sensitivity around 50–60% for IPA detection in influenza
[6, 44], but of less than 15% in COVID-19 [42].

CPA
CPA mainly affects patients with underlying lung diseases (sequelae of tuberculosis, nontuberculous
mycobacterial infections, lung cancer, bronchiectasis) and no or mild immunosuppression [2].
A suggestive chest CT imaging is the key element for diagnosis [2]. Presence of a fungus ball
(aspergilloma) in a pre-existing lung cavity is the most typical hallmark of CPA. Other radiological
patterns include expansion or wall thickening of a pre-existing cavity, parenchymal destruction or fibrosis
developing around a pre-existing cavity, pleural thickening or effusion, enlargement or pseudo-aneurysm of
a bronchial artery [2]. Aspergillus nodules are a distinct feature, which is often misdiagnosed for a lung
cancer because of its irregular or spiculated borders [2].

Microbiological documentation can be obtained by cultures on respiratory samples obtained by

noninvasive (sputum) or invasive procedures (bronchoscopy with BAL) [2]. Aspergillus PCR is a very
sensitive tool, but could be less specific than culture for the distinction between colonisation and infection
[2, 52]. Among patients under AF therapy for CPA, PCR can be useful for the detection of azole
resistance as a positive result was shown to be a good predictor [53].

GM testing can be performed in BAL with acceptable sensitivity (75–85%) and specificity (75–80%)
[2, 54, 55]. GM testing in serum has poor sensitivity and is not recommended [2, 56]. Detection of
anti-Aspergillus immunoglobulin G or precipitins has good positive predictive value for the diagnosis CPA
and acceptable sensitivity (75–80%) for aspergilloma but not for chronic cavitary pulmonary aspergillosis
[2, 57]. It is recommended for diagnosis and is also useful for the monitoring of response to therapy [2].

Treatment
AF drugs
Three AF drug classes are currently licensed for the treatment of aspergillosis (table 3): the polyenes
(amphotericin B formulations), the triazoles (voriconazole, posaconazole, isavuconazole, itraconazole) and
the echinocandins (anidulafungin, caspofungin, micafungin) [33, 34]. Some novel AF drugs with potent
anti-Aspergillus activity (e.g. olorofim, fosmanogepix) are currently under clinical investigation and are
available for compassionate use [58]. These drugs are expected to become key players for the treatment of
azole-resistant IPA.

Triazoles
Mould-active triazoles include itraconazole, voriconazole, posaconazole and isavuconazole. These AF
agents inhibit the biosynthesis of ergosterol and are fungicidal against most Aspergillus species with some
rare exceptions such as cryptic species of section Fumigati (e.g. A. lentulus, A. udagawae) and all species

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TABLE 3 Antifungal agents for the treatment of pulmonary aspergillosis

Antifungal Drugs Dosage Therapeutic use Comments

class

Polyenes Deoxycholate 1–1.5 mg·kg−1 once daily
amphotericin B (intravenous only)
Liposomal 3–5 mg·kg−1 once daily
amphotericin B (intravenous only)
Amphotericin B 5 mg·kg−1 once daily
lipid complex (intravenous only)
Amphotericin B 6 mg·kg−1 once daily
colloidal (intravenous only)
dispersion
Triazoles Itraconazole 200 mg once daily or twice
daily (intravenous or oral)
TDM recommended (target:
Ctrough: 1–4 mg·L−1)
Voriconazole Intravenous: 6 mg·kg−1 twice
daily (D1), then 4 mg·kg−1
twice daily
Oral: 400 mg twice daily (D1),
then 200–300 mg twice daily
TDM recommended (target:
Ctrough: 1–5 mg·L−1)
Posaconazole Intravenous or oral tablets:
300 mg twice daily (D1), then
300 mg once daily
Oral suspension: 200 mg three
times daily
TDM recommended (target:
Ctrough: >1 mg·L−1 for therapy
and >0.7 mg·L−1 for
prophylaxis)
Isavuconazole 200 mg three times daily
(D1–2), then 200 mg once daily
TDM not routinely
recommended (may be
considered)
Echinocandins Caspofungin 70 mg (D1), then 50 mg once
daily (intravenous only)
Anidulafungin 200 mg (D1), then 100 mg once
daily (intravenous only)
Micafungin 100 mg once daily (intravenous
only)
Should be avoided (privilege lipid
formulations of amphotericin B if
available)
Monitor kidney function and
Treatment of IPA (second choice after
electrolytes (K+)
triazoles; first choice in areas with high
prevalence of azole-resistant Aspergillus
Consider co-administration of
fumigatus isolates if no culture/fungigram
paracetamol if fever and/or rigors
available)
Treatment of IPA (privilege liposomal
Consider alternative therapy for
amphotericin B if available)
Aspergillus terreus
Treatment of IPA (privilege liposomal
amphotericin B if available)
Treatment of CPA
Treatment of IPA (first choice)
Treatment of CPA
Monitor hepatic tests (ALT, AST, ALP,
GGT, bilirubin)
Monitor ECG (QT interval, in
particular voriconazole)
Prophylaxis or treatment of IPA
Treatment of CPA (privilege itraconazole
DDIs (in particular voriconazole)
or voriconazole)
Oral suspension should be avoided or
Consider alternative therapy for
limited to prophylaxis (privilege
Aspergillus calidoustus or cryptic
intravenous formulation or oral tablets)
species of section Fumigati (e.g.
Aspergillus lentulus)
Treatment of IPA
Treatment of CPA (privilege itraconazole
or voriconazole)
Treatment of IPA as monotherapy (third
choice after triazoles and lipid
formulations of amphotericin B)
Treatment of IPA in combination with
triazoles (severe cases and/or positive GM;
azole-resistant Aspergillus fumigatus
isolates)

ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CPA: chronic pulmonary aspergillosis; D1: day 1; DDI:
drug–drug interaction; GGT: gamma glutamyltranspeptidase; GM: galactomannan; IPA: invasive pulmonary aspergillosis; TDM: therapeutic drug
monitoring, W1: week 1.

of section Usti (e.g. A. calidoustus), which account for a very low proportion of IPA (<3%) [59, 60].
Triazoles have the advantage to be available as intravenous and oral formulations. Their main side-effect is
hepatotoxicity, which is more frequent in patients treated with voriconazole and posaconazole (10–15%)
than in those treated with isavuconazole (<10%) [25, 61]. Hepatotoxicity may require treatment
interruption but is usually reversible. Triazoles are substrates and inhibitors of cytochrome P450
isoenzymes, which results in multiple drug–drug interactions [62]. These interactions are a particular
concern for voriconazole and may require dosage adaptations of other drugs, but they rarely prevent the
use of triazoles. With the exception of isavuconazole, triazoles may prolong the QT interval and require
electrocardiographic monitoring. Significant QT prolongation has been observed in about 15% of onco–
haematological patients and is associated with other medications affecting the QT interval and/or
electrolytic disorders in most cases [63]. Life-threatening complications (torsades de pointes) are very

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rare events. Therapeutic drug monitoring (TDM) is recommended for itraconazole, voriconazole and
posaconazole because of inter- and intra-individual variability of serum concentrations [34]. For
voriconazole, trough concentrations of 1 to 5.5 mg·L−1 have been proposed based on pharmacodynamic
studies correlating low and high concentrations with failure of therapy and toxicity (visual or neurological
disturbances), respectively [34, 64, 65]. Genetic polymorphisms in the CYP2C19, the cytochrome P450
isoenzyme involved in the primary metabolism of voriconazole, can explain inter-individual variations
between rapid and poor metabolisers [66]. For posaconazole, important variations of serum concentrations
have been observed with the oral suspension formulation and have been related to high gastric pH (e.g.
co-administration of proton pump inhibitors, type of food) [67]. More stable pharmacokinetic profiles are
observed with the new oral formulation (tablets) and the intravenous formulation [68]. However, TDM is
still recommended with targeted trough concentrations of 0.7 mg·L−1 and 1.0 mg·L−1 for prophylaxis and
treatment, respectively [34]. For isavuconazole, TDM is not routinely recommended because of more stable
pharmacokinetic profiles and lack of correlation between trough concentrations and outcomes [34, 69].

Triazoles represents the mainstay for the treatment of aspergillosis [2, 33, 34]. While voriconazole is
recommended as the first-line therapy of IPA [33, 34], new azoles (posaconazole, isavuconazole) have
demonstrated similar efficacy in randomised clinical trials [25, 61]. Isavuconazole is of particular interest
as it is associated with less hepatotoxicity, fewer drug interactions and more stable pharmacokinetic
profiles (i.e. no need for TDM) than voriconazole [25, 70]. The global emergence of azole resistance in
A. fumigatus, thought to be associated with the widespread use of fungicides in the environment, is of
particular concern [71]. Various mutations have been described in the azole target gene (cyp51A), the most
frequent ones being the TR34/L98H and the TR46/Y121F/T289A mutations, which are associated with
pan-azole resistance [72]. Patients receiving first-line voriconazole therapy for IPA due to an azole-resistant
A. fumigatus have significantly higher mortality rates compared to those infected with an azole-susceptible
isolate [73].

Amphotericin B
This AF agent binds to ergosterol, which results in altered integrity of the cell membrane with loss of
protons and monovalent cations [74]. The AF activity of amphotericin B may also result from production
of reactive oxygen species and oxidative damage [75]. It has a broad spectrum of AF activity and is
fungicidal against most Aspergillus species with the exception of A. terreus [74, 76]. Acquired resistance
among other Aspergillus species, such as A. fumigatus, is rare and mechanisms are poorly elucidated [77].

Over the last two decades, conventional amphotericin B deoxycholate has been substituted by safer lipid
formulations of amphotericin B, such as liposomal amphotericin B, amphotericin B lipid complex or
amphotericin B colloidal dispersion.

The use of amphotericin B is limited by its adverse events and its availability as an intravenous
formulation only. Nephrotoxicity is the main adverse effect, which was observed in one third of patients
treated with amphotericin B deoxycholate [78]. However, novel amphotericin B lipid formulations are
associated with reduced nephrotoxicity (10–15%) [78]. Other side effects, such as infusion-related
reactions (fever, rigors) and hypokalaemia are also significantly less frequent with the lipid formulations,
notably liposomal amphotericin B [78, 79].

One randomised study showed that amphotericin B deoxycholate was associated with lower rate of
therapeutic success and more drug-related adverse events compared to voriconazole [80]. Although data
from randomised controlled trials are lacking for liposomal amphotericin B, this drug has been associated
with success rates similar to those observed with voriconazole for IPA treatment [81].

Liposomal amphotericin B is a second-line therapy of IPA and the first-line therapy for azole-resistant
IPA [34]. It is also recommended as initial empirical therapy for suspected or possible invasive
mould infection because of its broader spectrum of activity against pathogenic moulds including
the Mucorales and azole-resistant Aspergillus species [34]. The local epidemiology regarding the
prevalence of these more resistant pathogens should be taken into consideration in the choice of initial
empirical AF therapy.

Echinocandins
Echinocandins inhibit the beta-glucan synthase, which results in loss of the fungal cell wall integrity [82].
Currently licensed echinocandins are caspofungin, anidulafungin and micafungin, which are available
only as intravenous formulations. Rezafungin is a novel molecule of this class with prolonged half-life that
can be administered once weekly [83]. Echinocandins have limited in vitro activity against Aspergillus

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species with a fungistatic effect resulting in blunted hyphae and growth inhibition [82]. In vitro and in
animal models, caspofungin displays a paradoxical effect (i.e. decreased efficacy at increased
concentrations), of uncertain clinical relevance [82]. Acquired echinocandin resistance may occur in
A. fumigatus via mutations in the beta-glucan synthase gene but this has been very rarely observed in clinical
isolates [82, 84].

In clinical practice, variable success rates have been reported with echinocandin monotherapy and there
is no randomised trials comparing the efficacy and safety of echinocandins versus amphotericin B or
triazoles [82, 85]. Currently, echinocandins are not routinely recommended for IPA treatment, except in
particular situations when underlying conditions or toxicity prevents the use of triazoles or amphotericin
B formulations [33, 34]. Echinocandins may be used in combination therapy with voriconazole in
severe IPA [34]. While this combination demonstrated some synergism in vitro and in animal models
[82, 86, 87], its superiority over voriconazole monotherapy could not be clearly demonstrated in a
randomised trial showing only a trend towards better survival with the combination and a significant
effect limited to the subgroup of patients with a positive GM [26]. This combination also represents a
therapeutic option for the treatment of azole-resistant IPA (as an alternative to liposomal amphotericin B),
but clinical efficacy in this setting is not demonstrated [88]. Some pre-clinical (in vitro and murine
model) and clinical data (single pilot study) also suggest a synergistic interaction between echinocandins
and amphotericin B [82, 89].

Novel AF agents
Because of the limited therapeutic options against azole-resistant IPA, novel AF drugs with potent and
broad anti-Aspergillus activity are warranted. Olorofim is an inhibitor of the fungal dihydroorotate
dehydrogenase, an enzyme involved in pyrimidine biosynthesis, which has a potent activity with a
time-dependent fungicidal effect against all Aspergillus species including those with intrinsic or acquired
azole resistance [58]. The prodrug fosmanogepix, which is converted to its active moiety manogepix by
systemic phosphatases, is an inhibitor of an enzyme in the glycosylphosphatidylinositol anchor
biosynthetic pathway (Gwt1) [58]. It has potent fungistatic activity against all Aspergillus species including
those with intrinsic or acquired azole resistance. Both compounds have the advantage to be available as
intravenous and oral formulations. They are currently in phase II clinical trials for the treatment of IPA
[58]. Ibrexafungerp is a beta-glucan synthase inhibitor with a structure distinct from echinocandins that can
be administered by oral route [58]. Its spectrum of activity against Aspergillus species is comparable to that
of echinocandins [58]. A phase II trial comparing ibrexafungerp given in combination with voriconazole
versus voriconazole monotherapy for the treatment of IPA is ongoing [58].

Within existing drug classes, other drugs with improved pharmacologic properties (e.g. tetrazoles,
encochleated amphotericin B) are in clinical phases of investigation [58].

Therapeutic approaches
IPA
AF therapy should be initiated promptly when IPA is suspected. When a bronchoscopy is planned, AF
therapy should be started after the procedure whenever possible, but should not be delayed by more than
24 h. The therapeutic approach of IPA in the different subsets of immunocompromised patients (e.g.
haematologic cancer patients, SOT, ICU patients) does not substantially differ. Triazoles (voriconazole,
isavuconazole or posaconazole) should be privileged for proven or probable IPA and liposomal
amphotericin B for possible IPA to ensure broad coverage including the Mucorales and azole-resistant
Aspergillus species. Other parameters, such as the baseline liver and kidney functions and the
co-medications with potential drug–drug interactions may also influence the choice of initial AF therapy as
described above. Combination therapies of triazoles and echinocandins should be limited to patients with
severe or refractory IPA. Surgical interventions are rarely necessary for IPA unless there is a need for
source control because of involvement of adjacent structures (e.g. pleura, mediastinum), extrapulmonary
foci (e.g. cerebral aspergillosis), life-threatening haemoptysis or nonresponsive disease. Bone-marrow
recovery or reduction of immunosuppression are important outcome determinants. Tapering of
immunosuppressive therapies should be considered very carefully in a multidisciplinary approach to avoid
graft rejection, GVHD or worsening of underlying immune diseases.

The duration of therapy is not well defined, but it should be at least 6–12 weeks depending on the recovery
of immunosuppression and the evolution of CT lesions that should be carefully monitored [33, 34]. Some
case series have addressed the role of positron emission tomography/CT in monitoring response to therapy
of invasive fungal infections with interesting results, which should be confirmed in larger datasets [10, 90].
Secondary prophylaxis should be considered in patients with prolonged immunosuppression [34]. Shorter

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treatment duration (e.g. 4–6 weeks) may be considered in immunocompetent ICU patients (e.g. influenza
and COVID-19) once they are discharged from ICU [46].

Chronic pulmonary aspergillosis (CPA)

The management of CPA is complex and requires a multidisciplinary approach involving pulmonologists,
thoracic surgeons, radiologists and infectious diseases specialists. As CPA may present with very
heterogeneous radiological patterns and degree of extension, indications for surgery should be carefully
assessed on an individual basis considering the number and size of the lesions and the patient’s underlying
structural lung disease and/or degree of lung function impairment [2]. In case of surgery, pre-operative AF
therapy may be warranted for complex surgical procedures to prevent spillage of the fungus (e.g. within
pleural cavity) [2]. Post-operative AF therapy should be considered in case of partial resection of the
lesion(s), complex procedures with risk of spillage or when histopathology or cultures show presence of
fungal elements invading the adjacent lung parenchyma [2].

In the absence of surgery, AF therapy may prevent progression of the lesions (e.g. fibrosis) and
life-threatening complications, such as haemoptysis, and improve respiratory conditions, quality of life and
outcomes [2, 91]. Long-term suppressive AF therapy is usually required as therapeutic response is very
slow and only partial in most cases. Regular chest CT (every 3 or 6 months) is indicated to assess
therapeutic response [2]. Oral triazoles are the cornerstone of CPA treatment. Itraconazole may be used as
first-line therapy because of its low cost and good safety profile [2, 91]. Voriconazole (or posaconazole)
can be administered for more severe disease [2, 92, 93]. Isavuconazole can be used in case of toxicity or
drug–drug interactions. Patients with long-term triazole therapy should have regular dermatologic control
(every 6 months) for the early detection of skin cancer [94]. Echinocandin therapy may be considered in
case of intolerance or resistance to triazoles [2, 95]. Rezafungin (administered only once a week) or the
novel oral beta-glucan synthase inhibitor ibrexafungerp may represent interesting alternative treatments
although data supporting their efficacy in CPA are currently lacking.

For patients who are not eligible for surgery and experience failure of AF therapy with recurrent
haemoptysis, direct instillation of amphotericin B or a triazole (itraconazole, miconazole) in the
aspergilloma cavity has shown some efficacy [2, 96].

Haemoptysis is the most feared complication and may require administration of tranexamic acid or arterial
embolisation in the most severe cases [2]. Surgery should be considered in case of severe or recurrent
haemoptysis [2].

Because of the paucity of clinical trials, management of CPA mainly relies on experts’ opinions [2]. A
multicentre collaboration has been recently initiated to establish an international registry (CPAnet), which
is expected to improve our understanding of the disease and to standardise therapeutic approaches [97].

Conclusions
With the advent of novel anti-cancer and immune modulation therapies and the recent H1N1 influenza and
COVID-19 pandemics, the incidence and clinical spectrum of pulmonary aspergillosis has increased
significantly. The heterogeneity of clinical and radiological patterns and limited sensitivity and specificity
of microbiological tests poses a diagnostic challenge. Clinicians should be educated to suspect and
recognise pulmonary aspergillosis among these new or atypical categories of patients where it is often
missed. Emergence of azole resistance among A. fumigatus is a major concern as current alternative
therapeutic options are limited. However, the development of novel AF drug classes are opening up
promising perspectives for the management of such cases.

Points for clinical practice

• The incidence and clinical spectrum of pulmonary aspergillosis are increasing because of the expanding
population at risk of developing the disease.
• Notably, pulmonary aspergillosis is increasingly recognised among patients with mild immunosuppressive
conditions or in apparently immunocompetent patients, such as those with severe influenza or COVID-19.
• The diagnosis of pulmonary aspergillosis is challenging because of the limited sensitivity and specificity of
diagnostic tests and the need to combine these tests for improved diagnostic accuracy.
• The treatment of pulmonary aspergillosis is challenging because of the limited number of available AF
drug classes and the emergence of resistance.

https://doi.org/10.1183/16000617.0114-2022 10
EUROPEAN RESPIRATORY REVIEW RESPIRATORY INFECTIONS | F. LAMOTH AND T. CALANDRA

Provenance: Commissioned article, peer reviewed.

Previous articles in this series: No. 1: Kumar K, Daley CL, Griffith DE, et al. Management of Mycobacterium avium
complex and Mycobacterium abscessus pulmonary disease: therapeutic advances and emerging treatments. Eur
Respir Rev 2022; 31: 210212. No. 2: Cilloniz C, Luna CM, Hurtado JC, et al. Respiratory viruses: their importance and
lessons learned from COVID-19. Eur Respir Rev 2022; 31: 220051. No. 3: Cavallazzi R, Ramirez JA. How and when to
manage respiratory infections out of hospital. Eur Respir Rev 2022; 31: 220092. No. 4: Reynolds D, Burnham JP,
Vazquez Guillamet C, et al. The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory
infections: another pandemic. Eur Respir Rev 2022; 31: 220068. No. 5: Puerta-Alcalde P, Garcia-Vidal C. Non-
Aspergillus mould lung infections. Eur Respir Rev 2022; 31: 220104. No. 6: Al-Tawfiq JA, Kim H, Memish ZA. Parasitic
lung diseases. Eur Respir Rev 2022; 31: 220093.

Conflict of interest: F. Lamoth has research funding from Gilead, MSD, Pfizer and Novartis, and has participated in
Advisory boards for Gilead, MSD and Pfizer. All contracts were made with and fees paid to his institution (CHUV).
T. Calandra has participated in advisory boards or consulted for Menarini, Shinogi, Cytosorbent, ThermoFisher and
GE Healthcare for projects unrelated to the submitted work and on data safety monitoring boards for Cidara and
Novartis. All contracts were made with and fees paid to his institution (CHUV).

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